As psychologists we work with people who may have difficulties with memory, ranging from mild inefficiency to significant memory impairment. Sometimes we are not aware of a person’s concern about their memory because they do not raise the issue. By contrast, some clients will describe a sense of anxiety, and even fear about memory, with an associated reduction in confidence that can have an impact on their everyday function. Significant memory issues related to brain injury or neurodegenerative conditions can present a challenge in our psychological practice. Asking about memory when working with clients can open up the opportunity to address any anxiety around memory.
Memory is sensitive to what is happening in people’s lives, and it is helpful to explore the reasons why memory may be a problem. Helping clients to understand how memory works can provide reassurance and lead to discussion about practical strategies to support memory and boost confidence in remembering.
Factors that influence memory
Carol, aged 51, has been referred for psychological consultation for assistance with the management of chronic back pain. Along with her pain, she describes disturbed sleep with hot flushes and night sweats occurring most nights. She has been spending a lot of time trying to find appropriate residential care for her mother who has Alzheimer’s disease, and she is stressed at work in her administrative role, as she has had to adapt to a new computer software system. Her teenage daughter is annoyed with her because Carol keeps forgetting things her daughter has said to her. Carol is worried that she is developing dementia. She has stopped going to her book club, because she finds she can’t always recall the details of what she has been reading, and she finds this embarrassing.
It will help Carol if she can understand which aspects of her health and lifestyle are likely to be influencing how her memory is working for her. Many women notice changes in their memory around the time of menopause. This life stage is often accompanied by a sense of overload, with multiple work and family commitments. While some studies have found subtle changes in some aspects of memory during menopause, research has not revealed consistent evidence of significant, related memory loss.
Results from a recent study conducted at the Royal Women’s Hospital in Melbourne showed that perimenopausal women were more likely to be dissatisfied with their memory than pre- and postmenopausal women, even though there was no difference between menopausal stage groups on objective memory assessment. The most frequent memory lapses included recalling names, finding words and difficulty concentrating.
In this study, perimenopausal women with a more negative attitude to menopause and more intense depressive, anxiety, vasomotor, and sleep symptoms were vulnerable to feeling less content with their memory (Unkenstein et al., 2016).
Carol described difficulties with sleep. For many women, hot flushes and night-time sweats interrupt sleep. The importance of sleep for memory function is well established Rasch & Born, 2013). It is also possible that Carol’s chronic back pain, or medications used to treat the pain, are affecting her ability to concentrate and pay attention. Carol’s confidence in her memory seems to have diminished, and she has withdrawn from some of her usual activities, such as her book club. When you doubt your memory ability it is common to avoid situations where you will need to use your memory.
Memory and age-related changes
Carol would benefit from gaining an understanding about how memory works. A simple information processing model (Baddeley et al., 2015) works well for explaining memory to clients. This model reinforces the idea that memory is not just one process, but can be thought of as being made up of several processes. It also helps to clarify terminology, as people use different labels for different parts of memory. For example, long-term memory can mean different things for different people. A model helps clients understand which parts of memory can become inefficient with the normal ageing process, or with the adverse influence of particular aspects of their health and lifestyle.
It is worth discussing the importance of our senses in memory formation. When we are forming a new memory, we need to first register the information with our senses. Any sensory changes can cause difficulties at this stage, and as we get older it is common to experience changes in hearing and vision. When there is sensory inefficiency, we need to dedicate more cognitive resources and effort to identifying incoming stimuli, which can reduce available resources for forming a memory of the stimulus.
A description of working memory helps to explain memory lapses that occur as a result of attentional disturbance. Working memory can be described as a small temporary memory store that holds and processes a limited amount of information.
Each new entry of information into this store wipes out previously held information. If we experience difficulty paying attention related to internal or external distraction, or age-related changes in attentional capacity, it makes it difficult for this stage of memory to work efficiently.
Many memory lapses are not so much memory, but attentional lapses. Clients like Carol may not, in fact, be forgetting information, but rather the information may not be getting into memory storage in the first place, because Carol has not paid attention to it.
Terms such as acquiring, storing and recalling can be used to explain the processes involved in forming a more durable recent memory. It is common for older adults to experience slowing in both acquisition and recall of memories. A particular aspect of recall that can change with age is the frequency of ‘tip of the tongue’ experiences, where we cannot find a specific word or name.
The ageing process can also affect prospective memory, or the ability to ‘remember to remember’ to do something on a particular day or time, such as taking your medication or going to an appointment. Clients can be reassured that forgetting is an adaptive part of our memory system, which stops us from becoming overloaded with information.
Highlighting aspects of our ‘lifetime’ memory store helps clients to realise that there are many aspects of their memory that remain strong. Lifetime memory can be described as a limitless store of more durable memories. Of course access to the specifics of some personal memories can change with time, but many older adults find it easier to recall information from their past than more recent details.
Lifetime memories include procedural memories, or the knowledge of how to do things, such as driving or playing a musical instrument. General and conceptual knowledge builds up over time and these lifetime memories are highly resistant to the ageing process. These strengths in memory as we get older are often referred to as our wisdom, and clients can be reassured that they can draw on their experience to gain perspective and work on resolving personal issues.
Confidence in memory has been shown to improve for older adults, and for peri- and postmenopausal women after attendance at a memory strategy group that included education and discussion about how memory works, memory changes related to ageing, health and lifestyle factors, and specific memory strategies (Kinsella et al., 2016; Unkenstein et al., 2017).
In our psychological practice, we can help individual clients to understand the workings of memory and normal age-related memory changes. When people become anxious that their memory lapses may be a sign of dementia, they can often be reassured by learning about expected memory changes that can occur with normal ageing.
We can assist clients to work on health, lifestyle and attitudinal factors that may be contributing to memory inefficiency, and to develop realistic expectations of their memory. Clients can be made aware of evidence-based strategies for maintaining their future brain health, such as regular physical exercise, social and mental stimulation (Livingston et al., 2017). Personalised practical memory strategies will also boost confidence in memory.
Practical memory strategies
As psychologists we can help our clients to nurture and support their memory as they experience challenging times. We can encourage our clients to be patient with themselves when it comes to memory. There will be times when they struggle to remember information, and that is OK. They need to know that they do not need to remember everything.
“The thing that you taught me that helped the most is to stay calm. Since I’ve made an effort to relax about my memory I feel like my memory has worked better”
Ratna, aged 59, after attending a memory strategy group
Helping clients to stay calm about memory is beneficial. We know that doing the opposite, and being anxious about memory, can actually promote memory lapses because anxiety can prevent us from focusing on incoming information. Clients can also be taught relaxation techniques such as mindfulness to enhance focus.
We can assist clients with prioritising and working out what is important for them to remember. For example, one client may want to focus on their difficulty with remembering to take medications, whereas another may want to work on being better at remembering people’s names. We can help clients to develop personalised memory strategies that will increase their confidence in remembering specific information.
Everyone is different, and everyone has their own preferences for memory strategies. For example, some people like to use the calendar in their phone for reminders, whereas others prefer to use a paper-based reminder system. Clients need to be encouraged to use strategies that suit them and their personal interests.
They will find that different strategies work for different situations. Asking clients if they use any particular techniques to help them remember is a good starting point. Some people have never used reminder systems whereas others already have systems in place. Building on a person’s pre-existing reminder system can work well, as they have already established a routine of using memory strategies.
Work with clients on developing a combination of internal and external strategies. Internal strategies involve some sort of mental manipulation and focus on enhancing acquisition and recall processes. These strategies typically involve focusing attention, adding meaning or reducing the amount of information to be remembered. Common internal strategies include ensuring understanding, associating new information with information that is known well, and visualisation.
“I remember the name of my friend Vee Lyn by imagining her playing the violin!”
Clare, aged 41
External strategies involve using some sort of external aid, such as a phone or diary, or making changes to the environment, such as having special places to store things. External strategies are generally easier to use than internal strategies and can be more effective for everyday remembering. Memory works best when we are organised. Strategies that become part of a person’s daily routine will be the most beneficial, as they reduce the demand on memory. There are several apps available to assist with developing organised reminder systems (see references). The ‘do it now!’ strategy helps with remembering to remember. If there is something you need to do later, do it now.
“I’ve tried writing things down as you suggested and I feel so much better about remembering things now”
Alex, aged 68, was referred with anxiety symptoms after being concussed in a car accident
Working with people who have significant memory impairment
Ralph, aged 73, has been referred for psychological consultation after a recent escalation of anxiety symptoms. He lives with his wife Audrey, and he has a longstanding history of anxiety. He was recently diagnosed with Alzheimer’s disease, and Audrey is finding it difficult to get Ralph to leave the house to attend his usual activities. Ralph reports not wanting to play golf, because he is finding it difficult to fill out the scorecard. He says he no longer attends his monthly Probus meetings because he can’t remember people’s names and has difficulty keeping track in group conversations.
People who experience memory issues related to brain injury or neurodegenerative conditions (such as Alzheimer’s disease) will benefit from working on health, lifestyle and attitudinal factors which could be exacerbating any underlying memory disturbance (Unkenstein, 2017). Ralph’s recent escalation in his anxiety symptoms is most likely partially related to his memory loss and the loss of confidence he feels when having to rely on his memory. His anxiety symptoms could be having a negative impact on his dementia-related memory loss.
The introduction of simple, supportive memory strategies could lessen Ralph’s anxiety, and help to maximise his ability to carry out his usual activities. Ralph could be encouraged to talk to his friends at golf about his difficulty with scoring, and to ask them to keep score for him. It can help to involve family members to support memory. If Audrey attends Ralph’s psychology consultations, she can remind Ralph about what was discussed in the session. Ralph may feel more comfortable attending his Probus meetings if Audrey accompanies him.
Audrey could encourage Ralph to talk to one person at a time, rather than a large group, and if she used the person’s name in conversation, this would act as a memory prompt for Ralph. Ralph and Audrey can be encouraged to think of activities that Ralph can take part in that he enjoys, which place less demand on memory, such as gardening or walking the dog.
Referring for medical or neuropsychological input
Toula, aged 28, developed post-traumatic stress disorder after being in a car accident where she had a whiplash injury. You notice that she regularly forgets what you have talked about in previous sessions, and she expresses concern about her memory. She hasn’t had her memory assessed following the accident. You wonder if Toula’s memory difficulties could be related to a possible brain injury at the time of the car accident.
Initially it will be helpful to liaise with Toula’s GP. She may have had medical tests or seen a specialist at the time of her car accident, and this information may be of assistance. Referring Toula to a neuropsychologist will enable her to gain a detailed understanding of her current memory function. The assessment will also help to identify the reasons why her memory is unreliable.
The assessment results will provide a basis for personalised strategy choice, including a focus on strengths by identifying abilities that remain unaffected, and an indication of other areas of cognitive impairment that will influence the advice you give. For example, if Toula has difficulties with planning and organisation related to a brain injury, she will benefit from implementing more structure and routine into her everyday life.
Bob, aged 57, was referred for strategies to enhance his sleep. He runs an international business and appears to be anxious and stressed with signs of depression. He has a history of heavy alcohol consumption since his early twenties and cardiac issues. During one session he says he is having difficulty with his memory.
Bob should be encouraged to see his GP in the first instance to check for any medical conditions that could be contributing to his memory difficulties. It would also be helpful to refer Bob to a neuropsychologist so that he can obtain objective feedback on how his memory is functioning. An understanding of Bob’s current cognitive strengths and weaknesses will allow you to work out the best approach in your work with him.
Memory-sensitive practice in focus
Memory-sensitive practice involves being alert to the presence of memory issues in our clients. In our work as psychologists we are often working with people who are experiencing more memory lapses than normal, as they negotiate a difficult time in their lives. At times we work with people who have more significant memory impairment related to brain injury or neurodegenerative conditions. A memory-sensitive psychologist will:
- ask clients about their memory
- work on identifying health, lifestyle and attitudinal factors that may be contributing to memory inefficiency
- explain how memory works
- understand normal age-related changes in memory
- assist with developing personalised and practical memory strategies
- involve family members if appropriate when memory impairment is significant
- develop techniques for supporting memory of session content, such as starting a session by running through what was discussed in the previous session, encouraging note-taking, and providing a written summary of key points or ideas to focus on between sessions, and
- know when to refer on for medical and/or neuropsychological input.
The author can be contacted at [email protected]